ANAMNESE TOMOGRAFIA

NOME:______________________________________________IDADE:_______

EXAME:___________________________________________________________

TCNICO:_________________________________________________________

MOTIVO DO EXAME:________________________________________________

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MOTIVO DA INTERNAO: ___________________________________________

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FUMA? (__) SIM / (__) NO

QUANTOS MAOS POR DIA? _______ A QUANTO TEMPO FUMA? ___________

J FEZ ALGUMA CIRURGIA? (__) SIM / (__) NO

QUAL? ___________________________________________________________

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J RETIROU A VESCULA BILIAR? (__) SIM / (__) NO

J RETIROU O APNDICE? (__) SIM / (__) NO

J RETIROU O TERO? (__) SIM / (__) NO

J TEVE ALGUM CANCER? (__) SIM / (__) NO

QUAL?

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OBSERVAO SOBRE O EXAME: _______________________________________

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AUTORIZA O USO DE CONTRASTE IODADO ENDOVENOSO? (__) SIM / (__) NO

ASSINATURA__________________________________________________

(PACIENTE OU RESPONSVEL)